REAFFIRMED GUIDELINES

No. 261 (Replaces No. 187, February 2007)

This guideline was peer reviewed by the SOGC’s Genetics Committee in January 2017 and has been reaffirmed for continued use until further
notice. Please note updated content can be reviewed in the Clinical Practice Guideline: No. 348-Joint SOGC-CCMG Guideline: Update on
Prenatal Screening for Fetal Aneuploidy, Fetal Anomalies, and Adverse Pregnancy Outcomes [September 2017].

No. 261-Prenatal Screening for Fetal

Aneuploidy in Singleton Pregnancies
This clinical practice guideline has been prepared by the Lola Cartier, MSc, CCGC, Montreal, QC
Genetics Committee of the Society of Obstetricians and
June Carroll, MD, Toronto, ON
Gynaecologists of Canada (SOGC) and the Prenatal
Diagnosis Committee of the Canadian College of Medical Valerie A. Désilets, MD, Montreal, QC
Geneticists (CCMG). It was approved by both the Alain Gagnon, MD, Vancouver, BC
Executive and Council of the Society of Obstetricians and
Gynaecologists of Canada and the Board of Directors of Jo-Ann Johnson, MD, Calgary, AB
the Canadian College of Medical Geneticists. Sylvie Langlois, MD, Vancouver, BC
PRINCIPAL AUTHORS Lynn Murphy-Kaulbeck, MD, Moncton, NB
David Chitayat, MD, Toronto, ON Nanette Okun, MD, Toronto, ON
Sylvie Langlois, MD, Vancouver, BC Melanie Pastuck, RN, Calgary, AB
R. Douglas Wilson, MD, Calgary, AB Vyta Senikas, MD, Ottawa, ON

SOGC GENETICS COMMITTEE CCMG PRENATAL DIAGNOSIS COMMITTEE

R. Douglas Wilson, MD (Chair), Calgary, AB Sylvie Langlois, MD (Chair), Vancouver, BC

François Audibert, MD, Montreal, QC David Chitayat, MD, Toronto, ON
Claire Blight, RN, Halifax, NS Isabelle DeBie, MD, Montreal, QC
Jo-Ann Brock, MD, Halifax, NS Suzanne Demczuk, PhD, Saskatoon, SK
Valerie A. Désilets, MD, Montreal, QC
Michael T. Geraghty, MD, Ottawa, ON
Key Words: Aneuploidy, Down syndrome, trisomy, prenatal
screening, genetic health risk, genetic health surveillance, prenatal Janet Marcadier, MSc, Ottawa, ON
diagnosis Tanya N. Nelson, PhD, Vancouver, BC
David Skidmore, MD, Halifax, NS
Vicky Siu, MD, London, ON
J Obstet Gynaecol Can 2017;39(9):e380-e394
Disclosure statements have been received from all members
[Link] of the committees.
Copyright ª 2017 Published by Elsevier Inc. on behalf of The Society of
Obstetricians and Gynaecologists of Canada/La Société des
obstétriciens et gynécologues du Canada

This document reflects emerging clinical and scientific advances on the date issued, and is subject to change. The information should not be
construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions.
They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written
permission of the publisher.

Women have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to
facilitate informed choice women should be provided with information and support that is evidence based, culturally appropriate and tailored to
their needs. The values, beliefs and individual needs of each woman and her family should be sought and the final decision about the care and
treatment options chosen by the woman should be respected.

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Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on
Preventive Health Care
Quality of evidence assessmenta Classification of recommendationsb
I: Evidence obtained from at least one properly randomized A. There is good evidence to recommend the clinical preventive action.
controlled trial. B. There is fair evidence to recommend the clinical preventive action.
II-1: Evidence from well-designed controlled trials without C. The existing evidence is conflicting and does not allow to make a
randomization. recommendation for or against use of the clinical preventive action;
II-2: Evidence from welledesigned cohort (prospective or however, other factors may influence decision-making.
retrospective) or caseecontrol studies, preferably from more D. There is fair evidence to recommend against the clinical preventive
than one centre or research group. action.
II-3: Evidence obtained from comparisons between times or places E. There is good evidence to recommend against the clinical preventive
with or without the intervention . Dramatic results in action.
uncontrolled experiments (such as the results of treatment with L. There is insufficient evidence (in quantity or quality) to make a
penicillin in the 1940s) could also be included in this category. recommendation; however, other factors may influence
III: Opinions of respected authorities, based on clinical experi- decision-making.
ence, descriptive studies, or reports of expert committees.
a
The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive
Health Care.1
b
Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the The Canadian Task Force on
Preventive Health Care.1

Abstract diagnosis would be offered to women who screen above a set risk
cut-off level on non-invasive screening or to pregnant women whose
Objective: To develop a Canadian consensus document on maternal personal, obstetrical, or family history places them at increased risk.
screening for fetal aneuploidy (e.g., Down syndrome and trisomy Currently available non-invasive screening options include maternal
18) in singleton pregnancies. age combined with one of the following: (1) first trimester screening
(nuchal translucency, maternal age, and maternal serum
Options: Pregnancy screening for fetal aneuploidy started in the mid
biochemical markers), (2) second trimester serum screening
1960s, using maternal age as the screening test. New
(maternal age and maternal serum biochemical markers), or (3)
developments in maternal serum and ultrasound screening have
2-step integrated screening, which includes first and second
made it possible to offer all pregnant patients a non-invasive
trimester serum screening with or without nuchal translucency
screening test to assess their risk of having a fetus with aneuploidy
(integrated prenatal screen, serum integrated prenatal screening,
to determine whether invasive prenatal diagnostic testing is
contingent, and sequential). These options are reviewed, and
necessary. This document reviews the options available for non-
recommendations are made.
invasive screening and makes recommendations for Canadian
patients and health care workers. Evidence: Studies published between 1982 and 2009 were retrieved
Outcomes: To offer non-invasive screening for fetal aneuploidy through searches of PubMed or Medline and CINAHL and the
(trisomy 13, 18, 21) to all pregnant women. Invasive prenatal Cochrane Library, using appropriate controlled vocabulary and key
words (aneuploidy, Down syndrome, trisomy, prenatal screening,
genetic health risk, genetic health surveillance, prenatal diagnosis).
Results were restricted to systematic reviews, randomized
ABBREVIATIONS controlled trials, and relevant observational studies. There were no
AFP alpha fetoprotein language restrictions. Searches were updated on a regular basis
and incorporated in the guideline to August 2010. Grey
CVS chorionic villus sampling
(unpublished) literature was identified through searching the
DR detection rate websites of health technology assessment and health technology
FPR false-positive rate assessment- related agencies, clinical practice guideline
collections, clinical trial registries, and national and international
FTS first trimester screening medical specialty societies. The previous Society of Obstetricians
hCG human chorionic gonadotropin and Gynaecologists of Canada guidelines regarding prenatal
screening were also reviewed in developing this clinical practice
IPS integrated prenatal screening
guideline.
MMS multiple marker screening
Values: The quality of evidence was rated using the criteria described
MoM multiples of the median in the Report of the Canadian Task Force on Preventive Health
MSAFP maternal serum alpha fetoprotein Care.
NT nuchal translucency Benefits, harms, and costs: This guideline is intended to reduce the
number of prenatal invasive procedures done when maternal age is
ONTD open neural tube defect
the only indication. This will have the benefit of reducing the
PAPP-A pregnancy-associated plasma protein-A numbers of normal pregnancies lost because of complications of
PR positive rate invasive procedures. Any screening test has an inherent false-
positive rate, which may result in undue anxiety. It is not possible at
SLOS Smith-Lemli-Opitz Syndrome this time to undertake a detailed cost-benefit analysis of the
uE3 unconjugated estriol implementation of this guideline, since this would require health

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REAFFIRMED GUIDELINES

surveillance and research and health resources not presently 8. Evaluation of the fetal nasal bone in the first trimester should not be
available; however, these factors need to be evaluated in a incorporated as a screen unless it is performed by sonographers or
prospective approach by provincial and territorial initiatives. sonologists trained and accredited for this service and there is
ongoing quality assurance (II-2E).
Recommendations
9. For women who undertake first trimester screening, second
1. All pregnant women in Canada, regardless of age, should be offered,
trimester serum alpha fetoprotein screening and/or ultrasound ex-
through an informed counselling process, the option of a prenatal amination is recommended to screen for open neural tube defects
screening test for the most common clinically significant fetal an- (II-1A).
euploidies in addition to a second trimester ultrasound for dating,
assessment of fetal anatomy, and detection of multiples (I-A). 10. Timely referral and access is critical for women and should
be facilitated to ensure women are able to undergo the type
2. Counselling must be non-directive and must respect a woman’s of screening test they have chosen as first trimester
right to accept or decline any or all of the testing or options offered screening. The first steps of integrated screening (with or
at any point in the process (III-A). without nuchal translucency), contingent, or sequential
3. Maternal age alone is a poor minimum standard for prenatal screening are performed in an early and relatively narrow
screening for aneuploidy, and it should not be used a basis for time window (II-1A).
recommending invasive testing when non-invasive prenatal 11. Ultrasound dating should be performed if menstrual or conception
screening for aneuploidy is available (II-2A).
dating is unreliable. For any abnormal serum screen calculated on
4. Invasive prenatal diagnosis for cytogenetic analysis should not be the basis of menstrual dating, an ultrasound should be done to
performed without multiple marker screening results except for confirm gestational age (II-1A).
women who are at increased risk of fetal aneuploidy (a) because of 12. The presence or absence of soft markers or anomalies in the 18- to
ultrasound findings, (b) because the pregnancy was conceived by
20-week ultrasound can be used to modify the a priori risk of
in vitro fertilization with intracytoplasmic sperm injection, or (c) aneuploidy established by age or prior screening (II-2B).
because the woman or her partner has a history of a previous child
or fetus with a chromosomal abnormality or is a carrier of a chro- 13. Information such as gestational dating, maternal weight, ethnicity,
mosome rearrangement that increases the risk of having a fetus insulin-dependent diabetes mellitus, and use of assisted repro-
with a chromosomal abnormality (II-2E). duction technologies should be provided to the laboratory to
improve accuracy of testing (II-2A).
5. At minimum, any prenatal screen offered to Canadian women who
present for care in the first trimester should have a detection rate of 14. Health care providers should be aware of the screening modalities
75% with no more than a 3% false-positive rate. The performance available in their province or territory (III-B).
of the screen should be substantiated by annual audit (III-B). 15. A reliable system needs to be in place ensuring timely reporting of
6. The minimum standard for women presenting in the second results (III-C).
trimester should be a screen that has a detection rate of 75% with 16. Screening programs should be implemented with resources that
no more than a 5% false-positive rate. The performance of the support audited screening and diagnostic laboratory services,
screen should be substantiated by annual audit (III-B). ultrasound, genetic counselling services, patient and health care
7. First trimester nuchal translucency should be interpreted for risk provider education, and high quality diagnostic testing, as well
assessment only when measured by sonographers or sonologists as resources for administration, annual clinical audit, and data
trained and accredited for this service and when there is ongoing management. In addition, there must be the flexibility and
quality assurance (II-2A), and it should not be offered as a screen funding to adjust the program to new technology and protocols
without biochemical markers in singleton pregnancies (I-E). (II-3B).

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INTRODUCTION include the provision of understandable information for

both patients and health care providers to ensure informed
S creening for chromosomal anomalies and open neural
tube defects is part of prenatal care offered to all Ca-
nadian women. Since the methods of screening for
decision-making, timely access to the screening test, a
system of notification of results and referral to follow-up
testing, and access to an intervention. The screening pro-
ONTDs have not changed since the mid-1970s, they are cess must allow patients to decline intervention at each step
not discussed here. Screening for ONTDs in Canada re- throughout the process. A screening program must include
quires second trimester serum alpha fetoprotein (16 to 20 regular clinical audit to evaluate local performance and
completed weeks) and/or ultrasound examination done at should have the flexibility to incorporate new technology.
18 to 22 weeks of gestation.
The Appendix provides a glossary of terms commonly
Screening for fetal chromosomal anomalies, including used in screening.
Down syndrome, began with amniocentesis in the mid-
1960s. At that time, the criterion for screening was
IMPORTANT CONCEPTS UNDERLYING PRENATAL
maternal age. In Canada, screening was offered only to GENETIC SCREENING
women
35 years at the expected date of delivery. This
was determined to be the point at which the risk of a Multiple marker screening uses a combination of maternal
pregnancy loss was less than the chance of identifying a age and 2 or more biochemical tests, with or without an
pregnancy with a significant chromosomal abnormality. ultrasound examination, to produce a single result for risk
This clinical practice guideline reviews the evolution of of Down syndrome, trisomy 18, and ONTDs, which is
screening for fetal aneuploidy from screening using used to offer options for clinical management. A screen is
maternal age alone to the many options currently available positive when the risk of one or more of the screened
and makes recommendations regarding the minimum disorders falls above a designated risk cut-off. Counselling
standard of prenatal screening that should be available to and further testing options are offered when a screen is
all Canadian women. The level of evidence and quality of positive. In the discussion of prenatal screening, the terms
recommendations are described using the criteria and false-positive rate or positive rate, and detection rate are
classifications of the Canadian Task Force on Preventive used (Appendix). As screening performance improves, the
Health Care1 (Table 1). FPR decreases and/or the DR increases. A risk cut-off
might be chosen based upon the desired DR, FPR, or a
WHAT IS SCREENING? combination of both. A risk cut-off is expressed as the risk
or likelihood of the condition being present in the fetus at
Screening is the process of surveying a population, using a term or at mid-trimester. The risk for the latter will be
specific marker or markers and defined screening cut-off higher, because 23% of fetuses with Down syndrome are
levels, to identify the individuals in the population at miscarried between mid-trimester and term (risk cut-off of
higher risk for a particular disorder. Screening is applicable 1:350 at term would be similar to 1:280 at mid-trimester).
to a population; diagnosis is applied at the individual pa-
tient level.2 The other commonly used term in multiple marker
screening is multiples of the median. Each marker result,
Screening for a disorder should be undertaken only when including both biochemistry and nuchal translucency
the disorder is considered to be serious enough to warrant measurements, can be expressed in MoM. The absolute
intervention. The marker or markers used in screening value of the assayed marker (serum or nuchal translucency)
must be sufficiently sensitive to identify a significant pro- is divided by the gestation-specific median value of the
portion of affected persons with minimal misidentification serum marker in the measuring laboratory or by using
of unaffected persons. There must also be both a highly standard or sonographer- specific curves for nuchal
accurate diagnostic test to determine whether the person translucency. This allows direct comparison of results be-
with a screen positive result truly has the disorder and an tween programs.
intervention available to all persons who are identified as
being affected. The screen, including follow-up testing and SCREENING FOR CHROMOSOMAL ANOMALIES
intervention, must be affordable. Finally the screen must
be acceptable to the population being screened. Traditionally, in Canada, the option of invasive testing was
recommended when a woman’s risk of having a pregnancy
The screening procedure should not be merely a test but with a chromosome anomaly was higher than the risks
must be a comprehensive program. The program must associated with the common invasive procedures

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REAFFIRMED GUIDELINES

(amniocentesis or CVS). New developments in maternal sperm injection,4 or because the woman or her partner has
serum and ultrasound screening have improved the ability a history of a previous child or fetus with a chromosomal
to identify pregnancies at increased risk for Down abnormality or is a carrier of a chromosome rearrangement
syndrome, trisomy 18, and other chromosomal abnor- that increases the risk of having a fetus with a chromo-
malities. This allows use of these screening tests to somal abnormality.
identify pregnancies at high enough risk to warrant inva-
sive diagnostic testing, which has a risk of pregnancy loss. In these scenarios, the risk of a chromosomal abnormality,
including chromosomal anomalies not detected by
The most common chromosome conditions associated screening, is high enough to offer invasive testing without
with advanced maternal age involve the presence of an prior screening.
additional chromosome (21, 18, 13, or X). Down syn- Recommendations
drome, trisomy 18, and trisomy 13 are associated with
congenital anomalies and intellectual disability. With 1. All pregnant women in Canada, regardless of age,
ultrasound and maternal serum screening, pregnancies should be offered, through an informed counselling
affected by these conditions can now be recognized with a process, the option of a prenatal screening test for the
significant degree of reliability. The practice of using solely most common clinically significant fetal aneuploidies
maternal age at the estimated date of delivery to identify in addition to a second trimester ultrasound for dating,
at-risk pregnancies should be abandoned. The maternal assessment of fetal anatomy, and detection of
age-related risk should be modified by additional non- multiples (I-A).
2. Counselling must be non-directive and must respect a
invasive markers, which consist of maternal serum
woman’s right to accept or decline any or all of the
markers and ultrasound assessment. The approach to
testing or options offered at any point in the process
screening and diagnosis may vary between provinces. It is
(III-A).
the responsibility of each health care provider to be aware
3. Maternal age alone is a poor minimum standard for
of what is available to his or her patients so that appro-
prenatal screening for aneuploidy, and it should not be
priate counselling is provided.
used a basis for recommending invasive testing when
non-invasive prenatal screening for aneuploidy is
INVASIVE PRENATAL DIAGNOSIS TO BE LIMITED available (II-2A).
TO WOMEN AT INCREASED RISK OF FETAL 4. Invasive prenatal diagnosis for cytogenetic analysis
ANEUPLOIDY should not be performed without multiple marker
screening results except for women who are at
The probability of conceiving a fetus with a trisomy increased risk of fetal aneuploidy (a) because of
increases with maternal age. Prenatal screening for chro- ultrasound findings, (b) because the pregnancy was
mosome anomalies starts with a discussion of the maternal conceived by in vitro fertilization with
age-related risk of having a baby with a chromosomal intracytoplasmic sperm injection, or (c) because the
abnormality. However, maternal age screening is inferior to woman or her partner has a history of a previous child
newer screening approaches that use multiple biochemical or fetus with a chromosomal abnormality or is a
markers with or without a first trimester ultrasound carrier of a chromosome rearrangement that increases
assessment of nuchal translucency. These strategies provide the risk of having a fetus with a chromosomal
a greatly reduced FPR with a substantially improved DR abnormality (II-2E).
when applied across all age groups, and they provide evi-
dence that the practice of offering invasive prenatal diag-
nosis for age alone as an indication should be abandoned.3 CHOOSING A SCREEN
Women
40 years should not be offered an amniocentesis
without prior screening, because with a negative screening The most appropriate screening test for Down syndrome
result, their risk of a clinically significant chromosomal would have the lowest FPR and the highest DR. Cost and
abnormality remains <1/200. Invasive prenatal diagnosis logistics should also be considered. Generally, the costs
for cytogenetic analysis should be offered only to women associated with screening are measured by the cost per
who are considered to be at increased risk of fetal aneu- Down syndrome pregnancy diagnosed. This has been
ploidy on the basis of a non- invasive screen result above estimated using different screening options in several
the risk cut-off, because of ultrasound findings, because studies.5e9 One of the difficulties with cost analyses is that
the pregnancy was conceived by IVF with intracytoplasmic the expenses associated with the ultrasound and serum

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Table 2. Current available screening options and their screening performancea

Screening option Markers Trimester Term risk cut-off DR, % FPR, % OAPR
Options that meet the minimum standard
FTS5,10 NT, free b-hCG, PAPP-A, MA 1st 1 in 325 83 5.0 1:27
Quad screening11 AFP, uE3, free b-hCG, inhibin A, MA 2nd 1 in 385 77 5.2 1:50
IPS5,10 NT, PAPP-A, AFP, uE3, free b-hCG/total 1st & 2nd 1 in 200 87 1.9 1:10
hCG, inhibin A, MA
IPS without inhibin A5 NT, PAPP-A, AFP, uE3, total hCG, MA 1st & 2nd 1 in 200 88 3.0 1:20
Serum IPS 5,10
PAPP-A, AFP, uE3, free b-hCG/total 1st & 2nd 1 in 200 85 4.4 1:26
hCG, inhibin A
Options that do not meet the minimum standard:
Maternal age12 MA 1st & 2nd 1 in 385 44 16 1:218
12
Triple screening AFP, uE3, total hCG, MA 2nd 1 in 385 71 7.2 1:59
MA: Maternal age; OAPR: Odds of being affected given a positive result.
a
Some centres in Canada may offer variation on IPS (sequential screening or contingent screening) with cut-offs set that achieve at least the minimum standard.

sample analyses vary greatly from one jurisdiction to Individual programs should determine what is appro-
another. In addition, cost has not been estimated for many priate for their jurisdiction.
screening options, including the second trimester ultra-
Recommendations
sound. Consequently, a comprehensive cost comparison
remains to be undertaken. 5. At minimum, any prenatal screen offered to
Canadian women who present for care in the first
Given geographic limitations and resource differences, it is trimester should have a detection rate of 75% with no
unlikely that a single screening protocol can be endorsed or more than a 3% false-positive rate. The performance
practically applied for all women across Canada; however, of the screen should be substantiated by annual audit
screening options should meet acceptable performance (III-B).
characteristics. Considering the tests currently available and 6. The minimum standard for women presenting in the
the risk and benefit ratio, it is believed that at a minimum, second trimester should be a screen that has a
screening programs should provide a screen that offers detection rate of 75% with no more than a 5% false-
women who present in the first trimester a DR for Down positive rate. The performance of the screen should be
syndrome of 75% with no more than a 3% FPR.10,11 For substantiated by annual audit (III-B).
women presenting in the second trimester, the screen
offered should have a minimum DR of 75% with no more REVIEW OF SCREENING OPTIONS
than a 5% FPR. Table 2 provides details of currently
available screening options and their screening perfor- First Trimester Screening: Nuchal Translucency
mance. Table 3 details timing of results for options that Combined With Biochemical Markers
meet the minimum standard. These include first trimester Nuchal translucency refers to the subcutaneous layer of
screening, quad screening in second trimester, 2-step in- fluid behind the fetal neck and lower cranium, which can
tegrated first and second trimester prenatal serum be visualized on ultrasound. In 1992, Nicolaides et al.18
screening with or without nuchal translucency (IPS and described an association between an increased size of
serum IPS).12 IPS can be offered as full integrated the nuchal translucency on the 11- to 14-week fetal ul-
screening for all women or as contingent or sequential trasound scan and an increased risk of fetal Down syn-
screening. Access to follow-up services should also be drome.18 Several large studies have shown that NT has a
ensured. Finally, prenatal screening programs must balance DR for Down syndrome ranging from 69% to 75%, with
minimizing the FPR (which minimizes the number of an FPR of 5% to 8.1%.5,10,19 This marker is associated
invasive procedures needed and thus the number of with other numeric chromosome abnormalities, other
normal pregnancies lost to chorionic villus sampling or fetal anomalies such as cardiac defects or diaphragmatic
amniocentesis) against the desire to detect as many cases as hernia, and a number of single gene disorders, particularly
possible as early in gestation as possible. Some studies those associated with decreased fetal movement. An NT
suggest women prefer a lower positive rate,13e15 while above the 99th percentile has a sensitivity of 31% and
others suggest that women want early diagnosis.16,17 specificity of 98.7% for major congenital heart defects

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REAFFIRMED GUIDELINES

Table 3. Available screening options that meet minimum FPR) and thus fulfills the guideline recommendation.5 FTS
standard also has the ability to screen for trisomies 13 and 18.
Screening methods that
meet guideline minimal Is 2nd trimester
Limitations on using FTS include the availability and
standard of 75% DR ultrasound still reproducibility of NT as well as the availability of chorionic
with 3% FPR Timing of results recommended? villus sampling as a diagnostic testing option for those with
1st trimester screen 1st trimester Yes a screen positive result. Guidelines for measuring NT to
2nd trimester quad 2nd trimester Yes maximize reproducibility and accuracy have been devel-
screen oped by the Fetal Medicine Foundation in the United
Two-step screens Kingdom.25 The Royal College of Obstetricians and
Contingent For most patients, result Yes Gynaecologists (United Kingdom) study group on first
available in 1st trimester; trimester assessment of Down syndrome recommended
small proportion of
patients require second that NT measurement should be implemented only in
trimester testing centres with appropriately trained sonographers using
Integrated Single result in 2nd Yes high-quality equipment, and that the results should be
trimester subject to regular audit by an external agency.26 The use of
Serum integrated Single result in 2nd Yes NT in a clinical setting requires a program of quality
trimester control and maintenance of skills through an ongoing audit
Sequential Results in 1st and 2nd Yes of NT measurements to achieve standardization and
trimester for the same
patient maintain the quality essential to obtain the desired DR and
FPR of the screening tests.27
Finally, if local ultrasound services are unable to provide
when the fetal karyotype is normal. One in 33 fetuses with a comprehensive screen for neural tube defects at 18 to
an NT above the 95th percentile (above 2.2 to 2.8 mm 20 weeks’ gestation, patients undergoing first trimester
depending on gestational age) and 1 in 16 with an NT screening for aneuploidy should be offered MSAFP in
above the 99th percentile (
3.5 mm regardless of gesta- the second trimester to screen for open neural tube
tional age) have a major cardiac defect detected.20 Finding defects.
an increased NT at 11 to 14 weeks’ gestation with a
normal fetal karyotype warrants offering a detailed ul- Ultrasound screening for delayed ossification of the fetal
trasound examination at 18 to 20 weeks, with an assess- nasal bone can be done in the first or second trimester.
ment of the fetal heart, including a 4-chamber view and The first trimester ultrasound, which determines the
view of the outflow tracts as a minimum21 or a fetal presence or absence of the nasal bone between 11 and 14
echocardiogram if available. weeks of gestation, may be more likely to be incorporated
into other screening modalities. First trimester assessment
Two first trimester maternal serum biochemical markers of the fetal nasal bone was described by Cicero et al.28
emerged at the same time as NT was being investigated. and detected 77% of Down syndrome cases. Subse-
These are PAPP-A and hCG (free beta or total). PAPP-A quent work has shown a DR of 68.8% and that the FPR
is lower in Down syndrome pregnancies and hCG is depends upon maternal ethnicity (9% in Afro-Caribbeans,
higher.22,23 In a study by Wald and Hackshaw that used a 5% in Asians, and 2.2% in Caucasians).29 The FPR also
combination of the maternal age-related risk, maternal varied with crown-rump length (increasing with
serum PAPP-A and free b-hCG, the DR of Down syn- decreasing crown-rump length) and NT (increasing with
drome was 61%, with a 5% false-positive rate.24 The first increasing NT).29 The difficulty in performing first
trimester biochemical markers alone were not as effica- trimester nasal bone sonography consistently in the
cious as second trimester screening; however, a combina- general population might limit the usefulness of this
tion of the 2 first trimester biochemical markers with NT, screening technique.30 A study of intra- and interoperator
demonstrated a significant improvement over second variability in fetal nasal bone assessment during the first
trimester triple and quadruple screening. FTS using trimester showed that the assessment was only fairly
maternal age, NT plus PAPP-A, and free b-hCG will reproducible.31 Guidelines for the ultrasound assessment
detect 83% of cases of Down syndrome, with a 5% FPR, of the nasal bone have been developed by the Fetal
using a term risk cut-off for Down syndrome of 1:300 (or Medicine Foundation.25 As with the use of NT, ultra-
will detect 78% of cases of Down syndrome with a 3% sound assessment of the nasal bone in a clinical setting

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requires a program of training, quality control, and A will increase the DR of Down syndrome by 10%.35,36
maintenance of skills through annual audit of nasal bone With a risk cut-off of 1:230 at term, the DR is 75% to
images. 80%, and the FPR is lowered to 3% to 5%, thus meeting
the minimal standard set by this guideline.5,10
Recommendations
7. First trimester nuchal translucency should be
Combined First and Second Trimester Options
interpreted for risk assessment only when measured
Integrated prenatal screening
by sonographers or sonologists trained and accredited
In an effort to further improve performance, the first and
for this service and when there is ongoing quality
second trimester screening tests have been combined into a
assurance (II-2A), and it should not be offered as a
process called integrated prenatal screening. Wald et al.37
screen without biochemical markers in singleton
predicted that integrating first and second trimester
pregnancies (I-E).
screening would result in an 83% DR for Down syndrome,
8. Evaluation of the fetal nasal bone in the first trimester
with a 2.1% FPR at a term risk cut-off of 1:200. IPS was
should not be incorporated as a screen unless it is
based on the use of PAPP-A and NT in the first trimester
performed by sonographers or sonologists trained and
and the quad screen in the second trimester, with results
accredited for this service and there is ongoing quality
released when all the testing was completed.37 This
assurance (II-2E).
9. For women who undertake first trimester screening, approach has been controversial, with some authors sug-
second trimester serum alpha fetoprotein screening gesting women had the right to know their results early and
and/or ultrasound examination is recommended to that it was unethical to withhold the first trimester results.38
screen for open neural tube defects (II-1A). However, when IPS utilizes a quad screen in the second
trimester, studies have shown a detection rate of 85% to
87% with an FPR of 0.8% to 1.5%.5,10 When Inhibin A is
Second Trimester Screening excluded from the IPS, the FPR increases to w2.5% when
In the 1970s, alpha fetoprotein was identified as a second the first trimester markers are performed at 12 weeks. Full
trimester marker for open neural tube defects. MSAFP integrated screening meets the guideline minimal standard.
continues to be used as part of multiple marker screening The benefit of IPS over FTS is the achievement of a lower
for this purpose, but is also effective as a screen for other FPR and reduction of the number of invasive diagnostic
open fetal defects such as gastroschisis and omphalocele. procedures needed.

In 1983, low MSAFP was noted in a patient who had a The optimal time for the PAPP-A measurement is 9 to 10
baby with trisomy 18.32 Further investigation showed this weeks’ gestation with the performance of PAPP-A
marker was low in Down syndrome as well,32 and for a few decreasing between 10 and 13 weeks. The proportion of
years, MSAFP combined with maternal age was used as a pregnancies in which a satisfactory NT measurement can
marker for Down syndrome. In 1988, Wald et al.33 be obtained is the highest at 11 to 13 weeks’ gestation. First
demonstrated that the combination of maternal age and trimester measurements are usually carried out between 11
MSAFP with two other maternal serum markers, uncon- and 14 weeks’ gestation as a compromise to make the
jugated estriol (MSuE3) and human chorionic gonadotro- timing favourable for NT and PAPP-A.5 IPS also screens
phin (MShCG), measured between 15 and 20 weeks’ for open fetal neural tube defects and trisomy 18.
gestation, would detect 65% of fetuses with Down syn-
drome using a 5% FPR.33 These predictions were Serum Integrated prenatal screening
confirmed in several subsequent studies.12,34 Triple marker When NT is not available, IPS still can be offered, using
screening has been available in Canada since 1991. Using a PAPP-A in the first trimester and triple or quad screening
term risk cut-off of 1:385, the triple marker screening in the second trimester. This approach has an 83% DR for
detects 72% of fetuses with Down syndrome with a 7% a 4% FPR.5 Alternatively, PAPP-A and free b-hCG can be
FPR.12 The triple marker screening also screens for offered in the first trimester, followed by AFP and uE3 in
ONTDs, other open fetal defects (e.g., gastroschisis, the second with virtually the same performance. The FPR
omphalocele), placental dysfunction, Smith-Lemli-Opitz is 4.2% if PAPP-A is measured at 10 completed weeks, and
syndrome, and trisomy 18. The triple screen does not the FPR is doubled (8.5%) if it is measured at 13
fulfill the guideline recommendation. completed weeks.5 In the FASTER trial, serum IPS
showed a 4.4% FPR for an 85% DR.10 Serum IPS is a
Inhibin A is a fourth marker that can be added in the practical option for areas of Canada where there is limited
second trimester, resulting in the quad screen. Inhibin or no access to NT screening.

SEPTEMBER JOGC SEPTEMBRE 2017 l e387

REAFFIRMED GUIDELINES

Given that timing is critical for serum analysis, accurate reported that 15.8% of cases had first trimester combined
dating of the pregnancy is very important. Ultrasound risk odds between 1 per 51 and 1 per 1500, thus requiring
dating should be performed if menstrual or conception second trimester serum marker analysis.44 The women in
dating is unreliable. For any abnormal serum screen (serum this intermediate risk group are likely to experience raised
IPS, quad) calculated using menstrual dating, an ultrasound anxiety, and a proportion of them might wish to have
should be done to confirm gestational age. invasive testing immediately, thus increasing the FPR.42,45
Recommendations
Sequential screening
10. Timely referral and access is critical for women and Sequential screening selects women for second trimester
should be facilitated to ensure women are able to testing on the basis of their first trimester screening results.
undergo the type of screening test they have chosen Women found to be at high risk on the basis of the FTS
as first trimester screening. The first steps of (e.g., risk
1 in 50) are offered invasive testing. Those with
integrated screening (with or without nuchal a risk lower than the cut-off are offered additional serum
translucency), contingent, or sequential screening are screening in the second trimester. The removal of screen
performed in an early and relatively narrow time positive affected cases in the first trimester decreases the
window (II-1A). prevalence of Down syndrome in the second trimester and
11. Ultrasound dating should be performed if menstrual
consequently lowers the PPV of second trimester serum
or conception dating is unreliable. For any abnormal
screening.46,47 As a result the overall cut-off is adjusted to
serum screen calculated on the basis of menstrual
take this into consideration. With appropriate cut-offs,
dating, an ultrasound should be done to confirm
sequential screening has been shown to perform equiva-
gestational age (II-1A).
lently to full integrated and contingent screening and meets
the guideline recommendation.42
Contingent screening
The concept of contingent screening has been suggested by Sequential screening that does not incorporate the results
Wright et al.39 as an alternative to IPS. In contingent of the first trimester testing into the second trimester risk
screening, the majority of women receive their result after analysis is associated with a significant increased FPR.5,6
FTS. Women at high risk (risk >1/50) are offered invasive
Given this high FPR, sequential screening should not be
testing, and women at low risk (risk <1/1500) require no
offered unless the second trimester risk incorporates the
further testing. A proportion of women with a risk between
first trimester results.
two cut-offs (1/50 and 1/1500) will go on to have second
trimester screening and will receive a combined result.
Benn et al.40 reported the expected screening performance POTENTIAL OF SCREENING OPTIONS TO DETECT
of the contingent strategy by modelling on different risk CHROMOSOMAL ANOMALIES OTHER THAN DOWN
SYNDROME AND OTHER GENETIC CONDITIONS
cut-offs and maternal age distributions of the United
Kingdom and the United States. Performance of contin- In pregnancies with trisomy 18, first trimester PAPP-A is
gent screening was comparable with IPS if total hCG and/ decreased, NT is enlarged, and second trimester serum
or free b-hCG was measured in both trimesters.40 It is levels of AFP, uE3, hCG, and inhibin A are significantly
possible to select risk cut- offs that achieve performances reduced.48e51 Many centres are now routinely screening
similar to IPS, thus meeting the guideline recommendation, for trisomy 18, using protocols designed for this anomaly.
while achieving detection of a significant proportion of With second trimester triple marker screening, at a term
abnormal pregnancies by the end of the first trimester.41,42 risk cut-off of
1:100, 60% of trisomy 18 pregnancies can
A study of computer simulations to compare integrated, be detected for a FPR of 0.2%.52 With serum IPS, using
sequential, and contingent screening strategies with various the same cut-off, the DR is 90% for a FPR of 0.1%.53
cut-offs leading to 19 potential screening algorithms A protocol for the detection of trisomies 13 and 18 has
showed that the contingent screening strategy had the best been developed for FTS.54
cost-effectiveness ratio, with fewer procedure-related
euploid miscarriages and unnecessary terminations.43 Studies show a large proportion of fetuses with triploidy
However, in contingent screening, a proportion of can be detected with the current MSS or FTS pro-
women are identified as having an intermediate risk and tocols.55,56 Second trimester uE3 is decreased and inhibin
asked to have the second trimester serum to modify their A is elevated in pregnancies with trisomy 13.57,58 Turner
risk. Using a prospective first trimester cohort of 18 901 syndrome is associated with a lower uE3. Higher hCG and
pregnancies and a contingent protocol, Cocciolone et al. inhibin A levels also are seen in cases where there is fetal

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 No. 261-Prenatal Screening for Fetal Aneuploidy in Singleton Pregnancies

hydrops.59e61 Increased NT and a lower PAPP-A have However, this should be done only in an established centre
been reported in pregnancies with triploidy of paternal performing tertiary level scans.
origin, trisomy 13, Turner syndrome, and other sex chro-
Recommendation
mosome aneuploidies.62e64 Trisomy 13 and 18, Turner
syndrome, and triploidy also are associated with anomalies 12. The presence or absence of soft markers or
and markers that allow the majority to be detected during anomalies in the 18- to 20-week ultrasound can be
the 18- to 20-week ultrasound. used to modify the a priori risk of aneuploidy
established by age or prior screening (II-2B).
Smith-Lemli-Opitz Syndrome is an autosomal recessive
disorder associated with intellectual disability and multiple
congenital anomalies. The minimum incidence is estimated FACTORS POTENTIALLY AFFECTING SCREENING
to be 1 in 60 000.65 SLOS is due to an abnormality in PERFORMANCE
cholesterol synthesis resulting in a low cholesterol con- A number of factors may affect screening performance.
centration and accumulation of its precursors in blood and These include accuracy of gestational dating, maternal
tissue.66 SLOS can be diagnosed prenatally by the presence weight, ethnicity, insulin-dependent diabetes mellitus, ac-
of abnormally elevated amniotic fluid 7-dehydrocholesterol curacy of NT and serum marker measurements, and the
concentration.67 In pregnancies with SLOS, maternal use of assisted reproduction technologies.
serum uE3, AFP, and hCG are reduced.68 A screening
protocol has been developed for this syndrome that pro-
vides a DR of 62% for a FPR of 0.33%.69 However, the Gestational Dating
screen is not specific for SLOS since it detects a number of Accurate dating is important. Ultrasound improves the
rare disorders of cholesterol and estriol biosynthesis, such precision of gestational age estimation, and hence reduces
as congenital adrenal hypoplasia and Zellweger syndrome, the standard deviation of each screening marker. This ef-
as well as a relatively common and mild disorder, X-linked fect is greater for markers whose concentrations change
steroid sulfatase deficiency (X-linked ichthyosis).70 most with gestational age. For all marker combinations, the
FPR is lower by about 2% when gestational age is esti-
mated using a scan. For example, for a DR of 85%, scan
THE USE OF ULTRASOUND IN SCREENING FOR dating could reduce the FPR of serum IPS from 4.2% to
CHROMOSOMAL ANOMALIES 2.7%.5
At 18 to 20 weeks’ gestation, all pregnant women should
be offered a detailed ultrasound that meets previously Maternal Weight
established minimum standards.71 Most major fetal There is a negative association between the levels of
anatomic abnormalities should be detected by this screen. maternal serum markers and maternal weight, which is due
In particular, the majority of open neural tube defects to the dilution effect produced by the physiologic increase
should be detected by this ultrasound.72 In addition, ul- in blood volume.84 The trend with first trimester markers
trasound can detect “soft markers,” which are features that is similar to that seen with second trimester markers.85
increase the a priori risk of fetal aneuploidy but can also be With second trimester screening, maternal weight adjust-
variations of normal. When used alone, second trimester ment increases DR by about 1% for a given FPR, or re-
ultrasound soft markers do not effectively discriminate duces FPR by 0.2% for a given DR.11 Weight adjustment is
between unaffected fetuses and fetuses with Down syn- beneficial if there is a marginally elevated AFP when
drome, because of the high positive rate from the large screening for ONTD. When interpreting measurements of
number of potential markers.73e76 Ultrasound soft serum markers, many screening centres routinely adjust for
markers were comprehensively reviewed in a 2007 SOGC maternal weight. It has been suggested that published
guideline,77 and both soft markers and anomalies identified weight correction formulas may not be optimal because of
in the 18- to 20-week ultrasound can be used to modify any differences in mean weight between the population served
a priori risk established by age or prior screening. In the and the populations used to derive the formulas. Each
absence of soft markers and anomalies, a reduction of risk laboratory should calculate its own weight adjustment
can be applied. In this circumstance, a conservative nega- formulas.84
tive likelihood ratio of 0.5 is often used, based on studies
that have shown an odds ratio, in the presence of a normal Weight adjustment does not appear to be necessary for NT
fetal ultrasound, ranging from 0.2 to 0.5578e86 unless risk adjustment, because it increases by only a clinically
centre-specific levels are determined through clinical audit. insignificant amount with increasing maternal weight.86

SEPTEMBER JOGC SEPTEMBRE 2017 l e389

REAFFIRMED GUIDELINES

Ethnic Origin IVF pregnancies.97,100,101 In 1999, Wald et al.97 suggested

There are differences in the levels of screening markers that adjustments for IVF pregnancies could avoid this high
between women of different ethnic origins after accounting FPR. However, results from a recent study in France based
for maternal weight. Maternal serum AFP is 15% higher, on w1000 IVF pregnancies found no differences in the
total hCG is 18% higher, inhibin A is 8% lower, and values of maternal serum AFP, uE3, and hCG between
PAPP-A is 35% higher in Black women than in Caucasian IVF pregnancies and controls. The FPR was similar in the
women. AFP is 6% lower, uE3 is 7% higher, total hCG is 2 groups.102
6% higher and PAPP-A is 17% higher in South Asian
women. Higher levels of first trimester PAPP-A and b- In the first trimester, a lower value of PAPP-A has been
hCG are seen in Asian women, and higher uE3 is seen in reported in IVF pregnancies, but data on NT and first
Aboriginal Canadian women.11,86e90 Adjusting for ethnic trimester free b-hCG remain inconsistent.101,103e106 Many
origin slightly increases the DR for a given FPR, but, more screening programs routinely collect information on IVF;
importantly, it tends to equalize the FPR among women of however, whether adjustment is necessary needs further
different ethnic groups.11 investigation.
Recommendation
Statistically significant differences in NT measurement
have been found between ethnic groups.90e92 However, it 13. Information such as gestational dating, maternal
seems these differences may be too small to warrant weight, ethnicity, insulin-dependent diabetes melli-
correction.88 tus, and use of assisted reproduction technologies
should be provided to the laboratory to improve
Insulin-Dependent Diabetes Mellitus accuracy of testing (II-2A).
Some second trimester serum markers tend to be lower in
women with insulin-dependent diabetes mellitus. After
weight correction, AFP is w10% lower and uE3 is w5% GENERAL CONSIDERATIONS
lower in diabetic women. No change in other markers in Screening practice differs across Canada and will also
diabetic women has been demonstrated.11,93,94 To allow change over time. Practitioners should stay updated on the
for the difference, the observed MoM for a woman with screening modalities available in their areas.
diabetes is divided by the corresponding median MoM in
diabetic women without Down syndrome pregnancies.
Because of the lack of data in diabetic women who have a Recommendations
Down syndrome pregnancy, a “pseudo risk” can be 14. Health care providers should be aware of the
calculated for diabetic women. screening modalities available in their province or
territory (III-B).
It appears that NT measurement, free b-hCG, and PAPP- 15. A reliable system needs to be in place ensuring timely
A in women with and without insulin-dependent diabetes reporting of results (III-C).
are not significantly different.95 16. Screening programs should be implemented with
resources that support audited screening and
Assisted Reproduction diagnostic laboratory services, ultrasound, genetic
When a pregnancy is a result of IVF, the maternal age used counselling services, patient and health care provider
for the determination of the risk of Down syndrome is the education, and high quality diagnostic testing, as well
age of the donor at the time the egg was harvested. as resources for administration, annual clinical audit,
and data management. In addition, there must be the
Data from most published studies show second trimester
flexibility and funding to adjust the program to new
serum levels of b-hCG and total hCG are higher, and uE3
technology and protocols (II-3B).
is lower in pregnancies conceived through IVF.96e99 There
were no significant differences in the levels of AFP and
inhibin A between IVF and non-IVF pregnancies.97 The
SUPPLEMENTARY DATA
variation in hCG is said to be driven by the continuing high
progesterone concentrations following hormonal treat-
Supplementary data related to this article can be found at [Link]
ment.97 Because of the higher hCG and lower uE3 levels, org/10.1016/[Link].2017.06.013.
the FPR of second trimester screening is nearly doubled in

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REAFFIRMED GUIDELINES

APPENDIX
SCREENING TERMINOLOGY

Affected individuals: Individuals who have the disorder for which the screen is being performed.
Cut-off level: The value of a test variable that distinguishes screen positive from screen negative results. The screening cut-off will affect both the
detection and false-positive rates: the higher the cut-off, the lower the false- positive rate and the lower the detection rate.
Detection rate (DR) or sensitivity: The proportion of affected individuals with positive screening results (usually expressed as a percentage).
False-positive rate (FPR): The proportion of unaffected individuals with positive screening results (usually expressed as a percentage). It is the
complement of the specificity.
First trimester window: The period between 11þ0 weeks and 13þ6 weeks of gestation.
Incidence: The number of new cases of a disorder that arise during a specific period of time, such as a year. This is usually expressed as a rate
per 1000.
Integrated prenatal screen (IPS): The use of markers in the first and second trimester to calculate the overall risk for fetal aneuploidy.
Likelihood ratio (LR): The likelihood that a given test result would be expected in a patient with the target disorder compared with the likelihood
that that same result would be expected in a patient without the target disorder. The likelihood ratio for a population is the detection rate divided
by the false-positive rate.
Multiple of the median (MoM): The observed value of a specific marker divided by the median value for that marker in a specified population (in
prenatal screening, usually pregnancies of the same gestational age).
Marker: A biological measurement that when present at an abnormal level may indicate the presence of disease.
Negative predictive value: The number of unaffected individuals with negative results (true negatives) divided by the total number of individuals
with a negative result, both affected and unaffected.
Odds of being affected given a positive result (OAPR): The ratio of the number of affected individuals with positive test results to the number
of unaffected individuals with positive results.
Positive predictive value (PPV): The number of affected individuals with positive results (true positives) divided by the total number of in-
dividuals with positive results, both affected and unaffected. It is the odds of being affected given a positive result expressed as a proportion or
percentage.
Positive rate: The sum of true and false positives. For most screens, the positive rate is virtually equal to the false- positive rate but as the FPR
decreases, this becomes a less reliable approximation. The screen positive rate is a useful parameter for the estimation of resource requirements
for follow-up services.
Prevalence: The number of cases of a disorder present at a point in time or during a specified period. This is usually expressed as a rate
per 1000.
Quality assurance: The policy, procedures, and systematic actions established in an enterprise for the purpose of providing and maintaining a
specified degree of confidence of a screening test.
Receiver operator curve (ROC): It is a plot of the true positive rate against the false-positive rate for the different possible cut points of a test. An
ROC curve demonstrates the trade-off between sensitivity and specificity (any increase in sensitivity will be accompanied by a decrease in
specificity). Accuracy of the test is measured by the area under the ROC curve.
Second trimester window: The period between 15þ0 weeks and 20þ6 weeks of gestation.
Specificity: The proportion of unaffected individuals with negative results.
Unaffected individuals: Individuals who do not have the disorder for which the screen is being performed.

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